Executive summary
The presence of waiting times in the health sector has been a long-standing challenge in many OECD countries, and the current COVID-19 pandemic will likely worsen waiting times for many non-urgent health services at least in the short-term. At the same time, waiting times are a reflection of the functioning of the health system as a whole and provide an opportunity for policy makers to trigger changes to improve the appropriateness, responsiveness and efficiency in health service delivery and to make health systems more people centred.
Waiting times for elective (non-urgent) treatment, which is usually the longest wait, have stalled over the past decade in many countries, and started to rise again in some others even before the COVID-19 outbreak. In response to the COVID-19 crisis, many countries have postponed elective surgery at least temporarily sometime during the first half of 2020 to free up a maximum amount of human resources and hospital beds to deal with the emergency. The postponement of these elective surgery will result in an immediate increase in waiting times for patients on the waiting lists and will result in a significant backlog of surgery that will likely take some time to be resolved after the crisis.
In normal circumstances, waiting times and waiting lists generally arise as the result of an imbalance between the demand for and the supply of health services. This can be for a consultation with a general practitioner or a specialist, or getting a diagnostic test or surgical or other elective treatments. Although some waiting times can improve the efficiency in the utilisation of resources by reducing idle capacity, when waiting times become long (e.g. above two or three months for elective treatments) more resources will need to be devoted by providers to manage waiting lists and prioritise patients and patient dissatisfaction will increase.
Several policies can be successfully implemented to reduce waiting times. Denmark, England and Finland succeeded in reducing waiting times for many elective health services and maintained these reductions over sustained periods, at least before the current COVID-19 crisis. The right policy mix for each country is likely to depend on the health system. However, successful approaches typically combine the specification of an appropriate maximum waiting time together with supply-side and demand-side interventions and a regular monitoring of progress.
All countries that want to address waiting times inevitably start by specifying a maximum waiting time, which requires a robust information system based on reliable data and definitions that capture the patient experience along the care pathway. There is no “one-size-fit-all” maximum waiting time. Countries have different maximum waits that reflect what can realistically be achieved given their starting point, the overall health spending, the additional resources they are willing to invest, and different institutional arrangements, payment systems and bottlenecks.
In some countries, maximum waiting times have been used as a target for providers and/or a guarantee for patients. Maximum waiting times have been used in England and Finland as targets with penalties for providers not meeting them. To meet the targets, providers need to implement demand and supply-side actions. Waiting time guarantees have been used in Denmark and Portugal and linked with patient choice policies, with patients being able to choose alternative health providers, including the private sector, if their waiting time approaches or exceeds the maximum.
On the supply side, only permanent and sustained increases in supply can lead to permanent reductions in waiting times. Lessons learned from past policies are that short-term interventions providing one-off additional funding do not have long-term effect on waiting times. Several countries (e.g. Australia, Canada, Estonia, Hungary, Ireland, the Netherlands, Poland and Slovenia) have allocated funding to increase the supply of services in some priority areas. Increasing the supply of services can be done in various ways. First, if there is slack in the system, then improving the management and efficiency in delivery (for example, through a better use of operating theatres) can be implemented at a relatively low cost. Increasing the productivity of providers is another option, for example by asking them to work additional sessions (and being adequately rewarded for it) or by introducing activity-based payment systems, though these are possible only if doctors and other members of health care teams have spare time and capacity to do more. Increasing the medical workforce is another option, if the productivity of the current workforce is already optimised, and if the physical and technical equipment (e.g. number of operating theatres) allows it, but this will be more expensive and will take more time before the effect can be felt.
However, even permanent increases in supply are not a guarantee of success. The main risk is that the additional supply is offset by an increase in demand, through an increase in referrals, tests and procedures, some of which may be inappropriate. For example, waiting times for some elective surgery in Canada and Australia have increased in recent years despite additional funding and surgical activities. Countries need to ensure that supply-side policies are linked to maximum waiting time enforcement to avoid disappointment. To ensure reductions in waiting times, a demand-side approach is also necessary to rationalise either GP referrals to specialists, or the propensity of specialists to add patients to a waiting list. In this respect, maximum waiting time targets (as used in England and Finland) can act as an indirect policy lever to ensure that when supply increases, providers do not offset these by increasing demand (through supply-induced demand or inappropriate referrals) but rather reduces the number of patients on the list, thereby translating into reduced waiting times.
Policy makers can also introduce several complementary and more direct approaches on the demand side to reduce waiting times for elective treatment (as in New Zealand). In the presence of large excess demand, clinical prioritisation tools that distinguish between patients with different health benefits and severity, can improve the referral process and the management of waiting lists. Prioritisation policies can also help to re-allocate waiting times by ensuring that patients with more severe conditions wait less than those with less severe conditions (as in Norway). Strengthening the referral systems from primary to secondary care, and improving the coordination between primary and secondary care, is another key policy in countries like Costa Rica, Finland and Poland, to ensure that resources are used efficiently and reduce waiting times.
OECD countries increasingly measure waiting times beyond elective treatment, including for primary care, cancer care and mental health services. Waiting times in primary care are less often considered a policy concern than for elective care, and only a few countries (such as Finland, Norway, and Spain) have implemented maximum waiting times to get an appointment with a general practitioner or other primary care providers. Policies to reduce waiting times in primary care often focus on increasing the supply of general practitioners, nurses and appointment slots. At the same time, more and more countries (such as Australia, Luxembourg and Estonia) have started to use new technologies to increase the supply of care (e.g. by offering teleconsultations) and to better manage demand (e.g. by allowing patients to more easily find doctors with availability and short waiting times).
Waiting times for cancer care are often shorter than for other types of care because of the urgency to get proper diagnosis and initiate treatment. In the majority of OECD countries, reducing waiting times for cancer care is considered an issue. More than half of OECD countries have developed waiting time strategies for cancer care covering both diagnosis and treatment, sometimes as part of national cancer control plans. Most countries set maximum waiting time targets and regularly evaluate their progress. Countries, such as Denmark, Ireland, Latvia, Poland, Slovenia and Spain, have also introduced fast track pathways for cancer patients, sometimes facilitated by additional dedicated funding and capacity. As for other elective treatment, increasing surgical activity rates for different types of cancer does not provide any guarantee that waiting times will fall if the demand increases. Countries, such as Finland, Greece, Japan, Luxembourg, the Netherlands, and Slovenia, have reorganised and streamlined cancer care delivery and improved coordination to achieve efficiency gains.
Waiting times policies for mental health services appear to be focused mainly on better meeting demand through increased service volumes or scope, rather than managing demand, possibly due to historical underfunding of mental health. Discussion of policies specifically tailored to reduce waiting times, or to improve the rate at which maximum wait time targets were met, was difficult to find. However, it appears that in some cases waiting time targets are part of a drive to increase overall access to mental health services, linked to a broader recognition that a significant treatment gap exists in the area of mental health. In some countries, such as Australia and England, new waiting time targets for mental health services have been introduced along with additional funding to increase service capacity, or even to introduce new service offers.
